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Mrs. Smith is a 65 year old African-American female presenting to the Intensive
Outpatient Therapy (IOP) program for the past 5 years. She initially presented for
therapy after her adult daughter encouraged her to do so. Mrs. Smith is divorced
and lives with her daughter and grandchildren.
Mrs. Smith has three children. Her eldest son, Vic, died in a fire at the age of 12.
Since Vics death, Mrs. Smith has developed a fear of chemicals and electricity. She
refuses to watch the television out of fear of an electrical fire. She cannot be in the
presence of gasoline and worries that those who pump the gas are contaminated
and may infect her. Therefore, she will not touch her daughter when she has come
from the gas station and demands that she take a shower to cleanse herself before
they even talk. Mrs. Smith has thrown out new clothes on multiple occasions due to
the poison packets that are sewn into the hem. She also avoids being driven by
the hospital where her son died (her daughter drives), even if this means taking a
very long and inconvenient route.
Mrs. Smith is a born-again Christian and attends church every Sunday for several
hours. She will only listen to gospel music. She does not exercise and takes
medicine for high blood pressure.
In the IOP group, Mrs. Smith has been observed to repeatedly and critically examine
her handwriting on the sign-in sheet and she cannot complete written exercises for
fear of doing them wrong. She has approached the facilitator repeatedly after
group asking what he wrote about her in his notes, asking if she did a good job.
She repeatedly reminds the facilitator to write details in his notes about Mrs.
Smiths son. When Mrs. Smith discusses her son in the IOP group, she calls him as
My oldest son who died when he was 12 years old. She becomes anxious if she
refers to him by name or simply as my oldest son. She has disclosed being fearful
of bad things happening if she omits details in conversation and repeatedly
corrects herself. On a bad day, she interrupts the group several times to disclose
corrections to what she has previously said.
Mrs. Smith is also being seen for individual psychotherapy where her therapist has
attempted Exposure and Cognitive Behavioral techniques. Mrs. Smith also visits
with a psychiatrist once a month for medication management. She is compliant with
her medicines, which include a high dose SSRI (Selective Serotonin Reuptake
Inhibitor) and benzodiazepine.
Mrs. Smith recognizes that some of her fears are irrational, but she cannot
withstand the anxiety she sustains if she does not follow mental or verbal rituals.
She says that her symptoms have truly begun to interfere with her daily level of
functioning though her daughter notes that Mrs. Smith was always ritualistic. Mrs.
Smith feels embarrassed and saddened by her condition and states that she is
constantly fighting with herself. She cannot escape feeling responsible for the safety
of her family and has experienced intrusive, unwanted images of her daughter
dying because of an error she could have prevented (for example, if Mrs. Smith

doesnt pray, she will be responsible for her daughter dying; if Mrs. Smith exposes
herself to gasoline, it will contaminate her and jump from her body to the walls of
her house, burning it down).

1) What might Mrs. Smiths diagnosis be?

2) How do you justify your diagnosis? (What are the hallmarks of this disorder
and how does Mrs. Smith meet criteria?)

3) What might your recommendations for treatment be?

4) What questions might you ask Mrs. Smith to help formulate a diagnosis and
treatment plan?